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0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 - Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sis;ov.org/ehd IJNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: If- o� er ; Inspection ate: S- L1 JP2 Facility Address: oS s, Service Request #: Onsite Service Technician's Name: ICC lerviceFechmcian/Installer Certification #: Manufacturer aining Receiv By: � it lu' ❑ ?.9AlL�,L 959 �'eZ SON& SERVICE rjZ�u ;•, L 2�� vA Leak detector ❑ ❑ mechanical Model: ❑ ❑ electronic Serial #: Receiv By: � ❑ line test programmed ❑ Leak detector ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ ❑ line test programmed Leak detector ❑ mechanical Model: ❑ ❑ electronic Serial #: ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) r Ie ,n SERVICE rjZ�u ;•, L 2�� vA Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. ❑ Caldwell System ❑ Other Receiv By: � Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary piping testing at: ❑ psi minutes Secondary containment repairs for: ❑ UDC(s) Piping Sump(s) UST(s) Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below 1 er TS7 44N l rjZ�u ;•, L 2�� vA THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. EHD Ins pec V Receiv By: � Title: 2�— EHD 23-04